Profound associations are found between the features of hoarseness and glottal configurations in both organic and functional dysphonia. Muscle tension dysphonia (MTD) type I with glottal chink and aphonia, and MTD type II-IV with supra-glottic contraction and rough hoarseness belong to major subtypes of functional dysphonia. Although these disorders could be diagnosed on the basis of these findings, the addition of voice therapy techniques improved the diagnosis. Generally, voice therapies are conducted by speech therapists and are unfamiliar to otolaryngologists; however, it may be beneficial to the diagnosis to perform simple voice therapies by laryngologists in person during the consultation of outpatients. We introduced two simple techniques : throat clearing and hamming, and were able to demonstrate the immediate effectiveness of hamming on vocal and laryngeal findings against subjects with MTD type II-IV findings, which were performed by a single laryngologist. In conclusion, the usefulness of tentative voice therapy conducted by a laryngologist was proved.
Thyroplasty was performed under local anesthesia on male-to-female transsexuals (MTF/GID) as well as patients with adductor spasmodic dysphonia (AdSD). There were 31 patients with MTF/GID who underwent type 4 thyroplasty during the period from 1999 to 2006. Voice fundamental frequency (F0) rose in all patients. Mean preoperative F0 was 135Hz, and postoperatively the mean value was 236Hz. Type 4 thyroplasty requires specialized skill, and was found to be effective for pitch elevation surgery in MTF/GID. Forty-one patients with AdSD underwent type 2 thyroplasty with Titanium Bridge between December 2002 and December 2005. These patients were followed up 1 year postoperatively with a questionnaire. 70% of the patients judged their voice as “excellent, ” and the remaining patients as improved to “good” or “fair”. Type 2 thyroplasty is a highly effective therapy for AdSD.
There are many options to treat laryngeal cancers : definitive irradiation with or without concurrent chemotherapy, endoscopic CO2 LASER surgery, partial surgery techniques, and total laryngectomy. Few studies have reported on vocal function and quality of life (QOL) of patients after definitive treatment for laryngeal cancer, using single voice related QOL measures. The aim of this study was to examine voice related QOL in patients treated with various modalities using questionnaires for Voice-Related Quality of Life (V-RQOL) and Voice Handicap Index-10 (VHI-10). Between August 2006 and February 2007, survey data from these questionnaires were obtained from a total of 130 patients. These patients had received definitive treatment for laryngeal cancers, were followed-up at the Hokkaido University Hospital, and were alive with no evidence of malignancy at the time of survey. The mean V-RQOL scores of the patients who had received radiation therapy (n=59), chemoradiotherapy (n=29), laser surgery (n=14) and total laryngectomy (n=26) as the final treatment for laryngeal cancer were 92.2, 92.9, 85.5, and 68.5, respectively, and the mean VHI-10 values were 2.95, 2.34, 5.43, and 11.12, correspondingly. Two patients who had received partial surgery were not included in this analysis. Such measures of quality of life are important to help judge overall effectiveness of treatment options for laryngeal cancers.
Both radiotherapy and laser surgery are known to be useful treatments for T1 and T2 glottic carcinoma and each modality has advantages and a disadvantages. One advantage of laser surgery is that it preserves the laryngeal function in comparison to other types of surgery. In addition, the indications for laser surgery have recently tended to be expanded. We herein report the indications for laser surgery in the treatment of laryngeal carcinoma, including the selection of the instruments, the surgical techniques in consideration of voice quality, and the outcomes of such surgery at our institution. Generally the laser surgery is considered to be a suitable procedure for the treatment of T1a glottic carcinoma and T1 supraglottic carcinoma. At our institution laser surgery is indicated for the Tis, T1, and T2 glottic carcinoma, for recurrent cases after radiotherapy, for cases desiring short term hospitalization, and for patients under 70 years of age. The CO2 laser is often used for a laser surgery on the larynx, because the associated tissue damage tends to be slight. Such laser surgery has important advantages in comparison to radiotherapy. These advantages include a shorter hospitalization and the avoidance of radiation induced cancer. On the other hand, laser surgery has disadvantages associated with local recurrence and the possibility of aggravating the vocal function. In laser surgery, we appropriately select the surgical margin and the depth depending on each case in order to prevent, local recurrence and acoustic disorders.
Objective : To compare the postoperative functional outcomes achieved in patients treated with supracricoid partial laryngectomies (SCPL) and fronto-lateral partial laryngectomies (FLPL). Patients : Twelve patients who underwent partial laryngectomies between July 2002 and October 2006 were evaluated. Four patients received SCPL, cricohyoidoepiglottopexy (CHEP) for three and cricohyoidopexy with one. Twelve patients had FLPL. Method : The postoperative vocal and swallowing functions of both groups were evaluated and compared. Acoustic parameters were recorded : fundamental frequency (F0), jitter, shimmer, noise to harmonics ratio (NHR) and maximum phonation time (MPT). Parameters of swallowing function were studied with video fluorography : amount of aspiration, pharyngeal residue, and method of nutrition intake. Result : Better functional results in acoustic parameters were achieved in patients managed with the SCPL procedure than with those managed by the FLPL procedure. All patients were able to swallow; however, all cases that underwent SCPL had experienced severe aspiration just after treatment. Speech therapists applied speech and swallowing therapies resulting in all patients being able to resume oral nutritional intake.
Twenty-four supracricoid laryngectomies with cricohyoidoepiglottopexy (CHEP) were performed for selected patients with laryngeal cancer in our institutions since December 2000. A retrospective chart review was performed to assess postoperative speech and swallowing function. Strobography and video fluorography of the neoglottis were utilized to assess speech and swallowing kinetics. Acoustic parameters were measured to evaluate vocal function and furthermore, several questionnaires were employed to evaluate the postoperative quality of life (QOL) of the patients. Without postoperative complications, stoma closure and normal diet intake were achieved 1 month after surgery. The neoglottis consists of the arytenoid (s), epiglottis and pyriform sinus mucosa. Several different combination patterns of these regions were observed between patients. The distance of laryngeal elevation and the width of the entrance to the esophagus were not affected by the surgical procedure, making normal diet intake possible. Even though vocalization sounded rough and breathy, vocal communication was possible with little inconvenience. Acceptable functional recovery and a tolerable QOL could be obtained after CHEP.
Highpoints of laryngomicrosurgery are described in this paper as the following : 1. Align head position appropriately for ideal exposure of the glottis. The appropriate posture for direct laryngoscopy is the “Flexion-Extension” position. Suspension laryngoscopy and external counter pressure contribute to optimal exposure of the glottis. 2. Selection of laryngoscope. Several types of laryngoscopes have been developed including round shaped, triangular shaped, retractable, etc. A posterior glottis laryngoscope was also developed for the management of posterior glottis lesions such as granulomas. It is important to have different types of laryngoscopes and to select the most appropriate one according to each lesion. 3. Selection of instruments. There are several kinds of cold instruments as well as laser equipment. It is also important to use these instruments properly for each type of lesion. 4. Surgical technique. Amputation or the micro-flap procedure should be selected for elevated lesions of the vocal fold on a case by case basis.
Type I thyroplasty and fat injection laryngoplasty are safe and useful methods for patients who suffer from breathy hoarseness due to unilateral vocal fold paralysis without any level difference between bilateral vocal processes. For these operations, various materials and procedures have been devised and used. However, the variability of injection materials and surgical procedures among facilities causes confusion in evaluating each treatment. In the present study, we laid out the basic methods and indications of these operations, and we insisted that satisfactory phonation is obtained by either the adequate material in the adequate place for type I thyroplasty or the accurate injection for fat injection laryngoplasty.
Introduction : Recurrent laryngeal nerve (RLN) palsy is one of the most serious complications in thyroid surgery. Intraoperative identification and preservation of the RLN is essential during thyroid surgery. The latest methods of intraoperative monitoring involve the use of special disposable endotracheal tubes with integrated electrodes. In Japan, no studies were available that evaluated whether the introduction of intraoperative neuromonitoring reduced the rate of RLN palsy. We reported our experience in using this monitoring system. Methods : Between October 2006 and June 2007, thyroid tumor surgery with intraoperative identification with and without additional intraoperative RLN neuromonitoring was performed on 53 patients. These cases were examined for postoperative nerve palsy, intraoperative blood loss and operation time. Result : The rates of RLN palsy based on nerves with or without intraoperative neuromonitoring at risk were 7.7% and 3.7% respectively. All nerve palsies were transient. These rates were not significantly different. Intraoperative blood loss and operation time were not significantly different in both group. Conclusions : The incidence of RLN palsy was not decrease by the use of intraoperative neuromonitoring; however, this monitoring system is not injurious to patients. Intraoperative neuromonitoring is recommended for high risk surgeries such as re-operation, the presence of a huge tumor, and low-volume surgeons.
We had previously demonstrated that an immediate nerve-muscle pedicle (NMP) transplantation to denervated thyroarytenoid (TA) muscle was effective in the recovery from atrophic changes due to successful reinnervation in rats. However, in a clinical situation, we usually treat patients suffering from persistent unilateral vocal fold paralysis. The objective of this study was to examine the effects of NMP transplantation on long-term denervated TA muscle in rats. Ten Wistar rats were divided into two groups; animals treated with left recurrent laryngeal nerve (RLN) transection alone (DNV group) and animals treated with NMP method at 16 weeks after RLN transection (NMP group). Both groups were euthanatized at 26 weeks after RLN transection. We evaluated the status of the neuromuscular junction (NMJ) and the muscle area histologically. In the NMJ, the ratio of the number of nerve terminals to that of acetylcholine receptors in the NMP group was significantly higher than that in the DNV group (p<0.01). With reference to the muscle areas, the ratios of the treated side to the normal side of the entire muscle and that of the individual muscle fibers in the NMP group were significantly higher than those in the Denervated group (p<0.01, p<0.05, respectively). Our study supported that up to 16 weeks after denervation, successful reinnervation can be established in denervated TA muscle by the NMP method.
In recent years, vocal fold augmentation surgery has been used increasingly as one of the effective rehabilitation operations to treat deficiency of glottal closure in the cases such as unilateral recurrent nerve paralysis. The fat tissue to be used in this technique has been primarily harvested from the subcutaneous region of the lower abdomen. It is often difficult to obtain sufficient fat tissue for injection due to the physical features of individual patient. For this reason, we have adopted a method to use fat tissue from the buccal fat pad, which is already used in other plastic surgeries. We evaluated and compared the histological characteristics of fat cells and the condition of vocal folds after injection fat tissue extracted from the subcutaneous region of the lower abdomen and from the buccal fat pad. Our findings were : (1) The size of buccal fat cells was relatively smaller compared with the size of those taken from abdominal region and was not influenced by BMI. There was less individual difference due to the physical features of the patient. (2) The number of vascular endothelial cells tended to be higher in buccal fat tissues. (3) Time until development of mucosal vibration during phonation after surgery was shorter in the cases of buccal fat compared with the cases using abdominal fat. (4) The percentage of the cases showing continuous effects for 6 months or more was slightly higher in the cases using buccal fat pad.
We performed laryngeal functional surgeries on four cases with supraglottic carcinomas. The procedures consisted of two horizontal partial laryngectomies, one subtotal laryngectomy with cricohyoidopexy, and one subtotal laryngectomy with tracheocricohyoidoepiglottopexy. In all four cases, the tracheostomy tube was removed after the operation and all were successful in deglutition. Swallowing function was almost normal in two cases and the other two cases, whose aryepiglottic folds had been resected, could tolerate a soft diet. While three cases had a slight aspiration on fluoroscopic pharyngogram examination, only two cases without aryepiglottic folds had subjective symptoms of aspiration. This suggests that there is an important relationship between the preservation of aryepiglottic folds and postoperative swallowing function. The pathological findings were : squamous cell carcinoma in two cases, basaloid squamous cell carcinoma in one and mucoepidermoid carcinoma in one. Surgical resection is recommended for basaloid squamous cell carcinomas and mucoepidermoid carcinomas as they are radiation resistant. One case had a local recurrence after chemoradiotherapy and three cases had locally advanced tumors (pT3 in two cases and pT4a in one), that were not expected to be cured completely by radiotherapy. Laryngeal functional surgery was chosen over radiotherapy in cases that exhibited pathologically radiation-resistance, radiation-failure, and locally advanced laryngeal tumor growth.
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